000301804P
31l 35 00(o 0003 01 r?(V
PERMIT R_
CITY OF CUPERTINO NUMBER
APPLICATION FOR
INSPECTION DIVISION PERMIT EXPIRATION -
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/
RESIDENTIAL — COMMERCIAL—OTHER—
OMMERCIALOTHEROWNER'S
OWNERS
HAZARDOUS FIRE AREA
!
VES ❑ If Y6
equ heatd. ClassA
NAME ✓�'�y'F� /�i%O
assembly is required.
NO Initial I.C.B.O. 11
q G Y b^ /%JiF/�K [ t7` Dom-
EXISTING ROOF COVERING
ADDRESS [
a5 -6r- oo 7C,
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S
NAME �oo�i ['x'� -
TO BE REMOVED TO BE RETAINED
/OeT�
"`[
ADDRESSCITY
TYPE OF ROOF COVERING
& ZIP y Sa o u usyL- c4.
EXISTING _xLC=,30 .t.'a SSG
ym 8' 7 3 a ^ �(O i j
PHONE
BUILT-UP ROOF ❑
LICENSE
NUMBER 7GcSa0
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
WOOD SHAKES t'
7`
effect. 3WOOD
76; 715--m O
SHINGLES]
License Class Lia Number
O�
Date 0930 ra Contractor ooh'' //u- •
OTHER (SPECIFY) El
OWNER -BUILDER DECLARATION
PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the
BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES El
axeAny violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars ($5001J:
I, do
WOOD SHAKES ❑
as owner of the property, or my employees with wages as their sole compensation, will
the work, and the structure is not Intended ar offered for sale (Sec. 7044, Business and Profes-
sions Cotle: The Contractor's License Law does not apply to an owner of property who builds or
WOOD SHINGLES El
thereon, and who does such work himself or through his own employees, provided that
such improvements are not intended or offered for sale. If, however, the building or improvement
such
is red within one year of completion, the owner -builder will have the burden of proving that he did
OTHER (SPECIFY) Elnot
build or Improve for purpose of sale.).
FJ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or improves thereon, and who contracts for such projects
with a contractogs) Iiceread pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
[:]1 am exempt under Sec. ,B 8 P. C. for this reason
Owner Dal.
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
1 have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
T^
%3
Building
as provided for by Section 3700 o1 the Labor Code, for the performance of the work for which this
permit is issued.
5..
p
7.i.�s
L]I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
„ `
Seismic
the Labor Code, for the performance of the work for which this permit is Issued. My Worker's
Total
Compensation Insurance carrier and Policy number are:
Carrier �y/�-�F Z;rc,.t'D Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
Yi•
V
GO
COMPENSATION INSURANCE N.C❑
This section need not be completed it the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this permit Is issued, I shall not employ
any person in any manner so as to become subject to the Workers' Compensation Laws of Cali-
shall be inspected prior to any roofing material being
fornia.
installed. If a root is installed without first obtaining an
Date —�o Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II, after making this Certificate of Exemption, you should became
Applicant understands and will comply with all non point
PP P Y P
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith cam
with such provisions or this permit shall be deemed revoked.
Source regulations.
I certify that I have read this application and state that the above information is correct I agree
to comply with all city and county ordinances and slate laws relating to building construction, and
All roof coverings to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for m-
spathe) purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,
"j_ e_ ^ AQ`v� • 1f.. —\
L,-fJ / % A./
coats and expenses which may in any way accrue against said City in consequence
ofthe
SIGNATURE OF APPLICANT DATE
gran
of the granting of this permit.
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS:
INSP. DATE
INSP. DATE
INSP DATE
TEAR OFF INSPECTION:
BATTENS:
FINAL:
INSP. DATE
INSP DATE
INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY